Evaluation and management of blunt traumatic aortic injury

Fox, Nicole; Schwartz, David R.; Salazar, Jose H.; Haut, Elliott R.; Dahm, Philipp; Black, James H.; Brakenridge, Scott C.; Como, John J.; Hendershot, Kimberly M.; King, David R.; Maung, Adrian A.; Moorman, Matthew L.; Nagy, Kimberly; Petrey, Laura B.; Tesoriero, Ronald; Scalea, Thomas M.; Fabian, Timothy C.

doi:10.1097/ta.0000000000000470

Cited by 150 publications

(67 citation statements)

References 50 publications

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“…27–32 Specifically, current data suggest that delayed repair of low-grade (1 or 2) blunt thoracic aortic injuries (BTAI) is safe, and endovascular therapy is recommended as first-line treatment by 2015 EAST guidelines. 27 Delayed repair of BTAI is justified in the polytrauma patient where more immediate life-saving interventions (e.g. emergent laparotomy or craniotomy) are prioritized, and the aortic injury is temporized by medical blood pressure control prior to definitive repair.…”

Section: Discussionmentioning

confidence: 99%

“…emergent laparotomy or craniotomy) are prioritized, and the aortic injury is temporized by medical blood pressure control prior to definitive repair. 27 However, patients with high-grade (3 or 4) blunt aortic injuries should not be considered for delayed repair. 28 Current EAST and WTA guidelines recommend endovascular intervention for blunt hepatic 29,30 and splenic 31,32 injury only in hemodynamically stable patients.…”

Section: Discussionmentioning

confidence: 99%

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Multicenter retrospective study of noncompressible torso hemorrhage

Chang

Fox

Greene

et al. 2017

Journal of Trauma and Acute Care Surgery

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Objective Rational development of technology for rapid control of non-compressible torso hemorrhage (NCTH) requires detailed understanding of what is bleeding. Our objectives were to describe the anatomic location of truncal bleeding in patients presenting with NCTH and compare endovascular (ENDO) versus open (OPEN) management. Methods Retrospective study of adult trauma patients with NCTH admitted to 4 urban level 1 trauma centers in the Houston and San Antonio metropolitan areas in 2008–2012. Inclusion criteria: named axial torso vessel disruption, AIS chest or abdomen ≥3 with shock (base excess <−4) or truncal operation in ≤90 minutes, or pelvic fracture with ring disruption. Exclusion criteria: isolated hip fractures, falls from standing, or prehospital CPR. After dichotomizing into OPEN, ENDO, and resuscitative thoracotomy (RT) groups based on the initial approach to control NCTH, a mixed-effects Poisson regression with robust error variance (controlling for age, mechanism, ISS, shock, hypotension, and severe head injury as fixed effects and site as a random effect) was used to test the hypothesis that ENDO was associated with reduced in-hospital mortality in NCTH patients. Results 543 patients with NCTH underwent ENDO (n=166, 31%), OPEN (n=309, 57%), or RT (n=68, 12%). Anatomic bleeding locations were 25% chest, 41% abdomen, and 31% pelvis. ENDO was used to treat relatively few types of vascular injuries, while OPEN and RT injuries were more diverse. ENDO patients had more blunt trauma (95% vs 34% vs 32%); severe injuries (median ISS 34 vs 27 vs 21), and increased time to intervention (median 298 vs 92 vs 51 min), compared to OPEN and RT. Mortality was 15% vs 20% vs 79%. ENDO was associated with decreased mortality compared to OPEN (RR 0.58, 95% CI 0.46–0.73). Conclusion Although ENDO may reduce mortality in NCTH patients, significant group differences limit the generalizability of this finding. Level of Evidence Level V (Prognostic and Epidemiologic)

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Multicenter retrospective study of noncompressible torso hemorrhage

Chang

Fox

Greene

et al. 2017

Journal of Trauma and Acute Care Surgery

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“…The Eastern Association for the Surgery of Trauma recommends that grade 3 injuries, defined as BTAI with pseudoaneurysm, undergo urgent endovascular repair,7 while the Society for Vascular Surgery (SVS) recommends early endovascular repair with medical therapy as a bridge to surgical intervention 8. However, in the setting of polytrauma in which a patient may present with major extrathoracic injuries, pharmacological management of blood pressure may obviate this option.…”

Section: Discussionmentioning

confidence: 99%

Thoracic aortic transection resulting in a type B dissection following blunt trauma

et al. 2017

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A 39-year-old man sustained an acute grade III aortic injury resulting in a type B aortic dissection in the setting of severe traumatic brain injury, cervical spine injury and multiple orthopaedic injuries following a motorcycle crash. The patient underwent an emergent thoracic endovascular aortic repair, complicated by a thoracic pseudoaneurysm rupture and ongoing exsanguination from a persistent type 1 endoleak. Additional stent grafts were required to gain control of the endoleak. The patient ultimately progressed to brain death post procedure in the intensive care unit. This case reviews treatment considerations in the context of a blunt thoracic aortic transection and distal dissection with concomitant polytrauma.

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“…Recently, many studies have shown a decrease in mortality in BTAI stable patients with delayed repair [14]. The Eastern Association for Surgery of Trauma recommends delayed repair with effective blood pressure control in this subset of patients [4].…”

Section: Medica Therapymentioning

confidence: 99%

“…In the past, the standard of care of traumatic vascular injuries was open surgical repair, and the in-hospital mortality for BTAI in the first 24 hours was up to 50% of patients [3,4]. However, in the last two decades, endovascular management for blunt trauma vascular injuries has significantly increased from 0.4% in 2002 to 13.2% in 2010.…”

Section: Introductionmentioning

confidence: 99%